onset of an episode of depression. The most impressive piece
`loss in light of the fact that the fantasied loss may be entirely
`of evidencelinking loss to subsequentdepressionis the finding
`unconscious,
`:
`.
`thatloss of a parent before age 11 places adults at a higher than
`Freud drew an analogy betweenserious melancholic states
`usual risk of depression, Some investigators have postulated
`and normal grief. Both may be time-limited, but Freud cited
`that early childhood losses or separations actually sensitize neu-
`two principal differences. In cases of grief, there is an actual
`tonal receptorsites in the brain, thereby producing a vulnera-:
`object loss in external reality; in depression the lost object is
`bility to mood disorders in adulthood. Persons who grow up
`more likely to be emotional than real. The seconddifference is
`with that enhanced vulnerability may be highly sensitive to
`that persons with depression experience profound loss ofself-
`images or ideas linked to depressive states, so that an episode
`esteem, butthe self-regard of persons engaged in a mourning
`of depression may be precipitated without requiring a cata-
`process is not diminished,
`strophic extemal loss. Chronic stress or deprivation of environ-
`The observational differences between-grief and depression
`mental ongin may produce alterations in the catecholaminergic
`were pivotal in Freud’s theory. He reasoned that one way of
`system in responseto stimulation from the corticotropin-releas-
`dealing with the loss of a beloved person is to becomelike the
`ing hormone-adrenocorticotropic hormone (ACTH)axis. The
`person, Freud defined that process as introjection, a defense
`end result of the changes may be the clinical picture of
`mechanism central
`to the psychodynamics of depression,
`in
`depression,
`which the patient internalizes the lost object so that it becomes
`Theeffects ofpsychosocial influences on newrophysiological
`an internal presence, Freud later noted that introjection is the
`,factors have been amply demonstrated in primate research,
`only way that the ego can give up a valued and loved object.
`‘Infant squirrel monkeys who are separated fromtheir mothers
`Because depressed personsperceive the departed love object
`experience long-lasting and, in some cases, permanent neuro-
`as having abandoned them, feelings of hatred and anger are
`biological changes. The changes include lasting alterations in
`intermingled with feelings of love. Freud suggested that ambiv-
`the sensitivity of noradrenergic receptors, changes in hypotha-
`alence ofthat nature, involving the coexistence oflove and hate,
`lamic serotonin secretion, and persistently elevated plasma cor-
`is instrumental in the psychodynamicsof depression. Asa result
`tisol levels, The sensitivity and the number of brain opiate
`of introjectingthelost object, the negativepart ofthe depressed
`receptors are also significantly affected by repeated separations,
`patient's ambivalence—the hatred and anger—is- directed
`Some of the changes are reversible if the infant monkeys are
`inward and results in the pathognomonic picture of self-
`reunited with their mothers or siblings; other changes are not.
`reproach. In that mannerasuicidal act may have the uncon-
`Moreover, the separations appear to be more orless damaging
`scious meaning of murder.
`:
`during certain developmental periods, possibly because of the
`Karl Abraham, one of Freud's early colleagues, shared
`correlation with myelinization in the nervous system.
`Freud’s view of depression butalso extended and elaborated it
`Tn the ensuing discussion of psychodynamic factors in the
`further. Abraham viewed the process of introjection as a
`etiology of depression, the reader must keep in mindthat psy-
`defense. mechanism that takes two forms. First, he thought that
`chologicalinfluences work in concert with genetic vulnerability
`the introjection of the original love objectis the basis for build-
`and neurophysiological alterations to produce the characteristic
`ing one’s ego-ideal, so that the role of the conscience is even-
`clinical picture of depression. Those characteristics include psy-
`tually taken over by the introjected object. In that conceptual-
`chomotorretardation, sleep changes, loss of appetite, dimin-
`ization muchof pathological self-criticism is seen as emanating
`ished sex drive, anhedonia, loss of energy, inappropriate guilt
`from the introjected love object, In the second form ofintro-
`feelings, and suicidal ideation. Similarly, comprehensivetreat-
`jection, more in keeping with Freud's idea, the contentof self-
`ment planning must take into account both the psychodynamic
`reproach is merciless criticism directed at the object. In other
`factors and the alterations of neurotransmitters.
`words, Abraham viewed the two processes of introjection as
`One ofthe most sophisticated efforts to define the relative
`instrumental in the creation of the superego, Abraham also
`contributions of psychological vulnerability, genetics, and enyi-
`linked depression to early fixations at the anal and the oral levels
`ronmental stressors in major depressive disorder was a predic-
`of psychosexual development. He viewed oral sadistic tenden-
`tion study involving female twins, Multiple assessments of 680
`cies as the primary source of self-punishment in depressed
`female-female twin pairs of known zygosity were made over
`patients, and he inferred that inadequate mothering during the
`time, and the findings allowed the investigators to develop an
`oral stage of development was involved.
`etiological modeltopredict major depressive episodes. One of
`The psychodynamic understanding of depression defined by
`the mostinfluential predictors was the presenceofrecentstress-
`Freud and expanded by Abraham is known astheclassical view
`ful events. Genetic factors were also importantin prediction of
`of depression. That theory involves four key points: (1) Distur-
`depression. Two other factors, neuroticism and interpersonal
`bances in the infant-motherrelationship during the oral phase
`relations, also played a substantial etiological role. Neuroticism
`(the first 12 to 18 monthsoflife) predispose to subsequent vul-
`seemed to contribute in part by reducing the level of social
`nerability to depression. (2) Depression can be linked to real or
`support for an individual. Interpersonal dimensions of social
`imagined objectloss. (3) Introjection of the departed object is
`Support,
`recent difficulties, and parental warmth all were
`a defense mechanism invoked to deal with the distress con-
`involved in predicting a major depressive episode.
`:
`nected with the object
`loss.
`(4) Because the lost object
`is
`regarded with a mixture of love and hate, feelings of anger are
`directed inwardatthe self.
`
`PSYCHODYNAMIC THEORIES OF DEPRESSION
`
`Anger turned inward A common finding in depressed
`patients is profound self-depreciation. Sigmund Freud, in his
`classic 1917 paper “‘Mourning and Melancholia,’ attributed
`that self-reproach to anger turned inward, which herelated to
`object loss. The object loss may or may notbe real. A fantasied
`loss may be sufficient to trigger a severe depression. Moreover,
`the patient may actually be unaware of any specific feelings of
`
`Depressive position Although Melanie Klein understood
`depression as involving the expression of aggression toward
`loved ones, much as Freud did, the developmental theory on
`which her view was based is quite different from Freudian the-
`ory. During thefirst year oflife, Klein believed, the infant pro-
`gresses from the paranoid-schizoid position to the depressive
`position, In the first few monthsoflife, according to Klein, the
`
`
`
`SECTION 16.5 / MOOD DISORDERS: PSYCHODYNAMIC ETIOLOGY
`
`1117
`
`
`
`
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`

`
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`1118
`
`MOOD DISORDERS / CHAPTER 16°
`
`infant projects highly destructive fantasies into its mother and
`then becomesterrified of the motheras a sadistic persecutor.
`That terrifying “‘bad’’ mother is kept separate from the loving,
`nurturing ‘‘good’’ mother through the defense mechanism of
`splitting. In that manner the infant's blissful feeding experience
`remains uncontaminated and undisturbed by persecutory fears
`of attack by the ‘‘bad’’ mother. In the course of normal devel-
`opment, according to Klein, the positive and the negative
`images of the mother are integrated into a more ambivalent
`view. In other words, the infant recognizes that the “‘bad”’
`mother it fears and hates is the same mother as the ‘‘good’’
`motherit loves and adores. The recognition that one can hurt
`loved onesis the essence of the depressive position.
`Klein connected clinical depression with an inability to suc-
`cessfully negotiate the depressive position of childhood. She
`regarded depressed persons as fixated or stuck at a develop-
`mental level in which they are extraordinarily concerned that
`loved good objects have been destroyed by the greed and
`destructiveness they have directed at them. In the absence of
`those good objects, depressed persons feel persecuted by the
`hated bad objects, In short, Klein's view was that depressed
`patients are longing or pining for the lost love objects while
`being persecuted by bad objects. In that theoretical framework
`the feelings of self-depreciationare linked to the fear that one’s
`good parents have been transformed into violent persecutors as
`a result of one’s own destructive tendencies. Also, the bad inter-
`nal objects are internalized into the superego, which then makes
`sadistic demands on the patient. Hence,in the Kleinian view,
`the self-reproaches experienced by depressed patients are
`directed against the self and internal
`impulses, rather than
`toward an introjected object, as in Freud’s view.
`
`of a sadistic intemal tormentorthat is unrelenting in its victim-
`ization, Jacobson also noted that the boundary betweenself and
`object may disappear, resulting in a fusion of the bad self with
`the bad object.
`
`Dominant other Silvano Anti studied the psychodynamic
`underpinnings of depression in severely ill patients who were
`unresponsive to most somatic treatments. He observed a com-
`mon psychological themein those patients that involved living
`for someoneelse, rather than for themselves. He referred to the
`person for whom depressed patients live as-the dominantother.
`In most cases the dominant other is the spouse or a parent, but
`Arieti also noted that sometimes a principle, an ideal, or an
`organization serves a similar psychodynamic function, In such
`cases he referred to the entity as the dominant ideology or the
`dominant goal.
`Depression often sets in whenpatients realize that the person
`for whom they have been living is never going to respond in a
`mannerthat will meettheir expectations. The goalof their lives
`is regarded as unattainable, and a profound feeling of helpless-
`ness sets in, In Arieti’s conceptualization of depression, he
`stressed a markedrigidity in the thinking of depressed persons,
`so that any alternative to living for the dominant other or the
`dominant ideologyis viewed as unacceptable and even unthink-
`able. Depressed patients feel locked into an inflexible perspec-
`tive on how they should live their lives and how gratification
`or fulfillment can be obtained. Even though they are depressed
`because living for someone or something other than themselves
`has been a failure, they nevertheless feel paralyzed and unable
`to shift their approach to life. If the dominant other will not
`respond to them in the way they have longedfor, they fee] that
`life is worthless, and that rigidity is often involved in a decision
`that suicide is the only alternative.
`
`Tension between ideals and reality Whereas most psy-
`chodynamic theories of depression incorporate the superego as
`CASE EXAMPLE A 19-year-old college student consulted a
`psychi-
`a significant part of the conceptual understanding, Edward Bibr-
`atrist after one semester in school. He told the psychiatrist that
`he was
`ing viewed depression as tension arising from within the ego
`depressed and discouraged with college and with himself, College was
`itself, rather than between the ego and the superego. According
`not what he had expected, and he had
`not
`performed up to his expec-
`tations. He was seriously questioning whether he should return for the
`to Bibring, the ego has three highly invested narcissistic aspi-
`second semester, and he had a sense of hopelessness about changing
`rations—to be good and loving, to be superiororstrong, and to
`his feelings. Suicidal thoughts had occasionally crossed his mind,
`be loved and worthy. Those ideals are held up as standards of
`although he was not planningto act on them, His sleep was disturbed
`conduct, Depression sets in when a person becomes aware of
`by awakening in the middle of the night and ruminating about what he
`should do.
`He felt a significant diminution in his energy level, and he
`the discrepancy between those ideals and reality. Helplessness
`poniannpten that things he used to find enjoyable no longer gavehim
`leasure,
`;
`and powerlessness:result from the feeling that one cannot mea-
`x The patient attended a prestigious college on the West Coast, but he
`sure up to such high standards. Any blow to the self-esteem or
`indicated that he had actually wanted to get into Harvard. His appli-
`any frustration ofthe strivings toward those aspirations precip-
`cation to Harvard had resulted in his being placed on the waiting list,
`itates depression. Bibring's theory, unlike Freud’s and Klein's.
`but he had not been accepted. The psychiatrist he consulted commented
`does not regard aggression as playing a primary role in depres-
`that the college he had chosen to attend wascertainly a highly regarded
`one, The patient responded, ‘‘It’s not Harvard."’
`When the psychiatrist
`sion. The depressed person may ultimately experience anger
`asked thepatienthow he had done academicallydurin theHirst semes-
`turned inward, resulting from the awareness of helplessness;
`ter, the patient appeared embarrassed and reeled, “Tonly got a 3,25
`however, such expressions of aggression are secondary, rather
`prade-point average—one A andthree Bs.’*
`Thepsychiatrist askedhim
`why he seemed embarrassed lo reveal such a solid academicrecord.
`than primary, The essence of depression, in Bibring’s view, is
`The patient explained that he hadwanted to make the dean's list but
`a primary affective state arising within the ego and is based on
`thathehad fallen short ofit, since the list required a 3.5 grade-pount
`the tension between what one would like to be and what one
`average.
`—
`;
`:
`we
`is.
`:
`The psychiatrist asked the
`patient if he hoped to be in a different
`situation after one semester of college. The patient's answer reveal
`that he had an extraordinarily high internal expectation of himself. He
`had wanted to be ‘‘a star,"’ a_straight-A student at Harvard. He
`explained that his fathér-had gone to Harvard, and he hoped that, ‘by
`being a standout there, he wouldfinally achieve thepape and recog
`nition from his father that he had always longed for but had never
`received. His father seemed disappointed that his son had not been
`accepted to Harvard, and the patient was convinced that his father was
`ashamed ofhis son for not making the dean's list.
`-
`
`Ego as victim of superego Edith Jacobson compared the
`state of depressionto a situation in which the egois a powerless,
`helpless child, victimized by the superego, which becomesthe
`equivalentof a sadistic and powerful mother who takes delight
`in torturing the child. Like Freud, Jacobson assumedthat
`depressed persons have identified with ambivalently regarded
`lost love objects. The self is experienced as identified with the
`EXPLANATION~The above case exampleillustrates the psycho-
`negative aspects of the object, and ultimately the sadistic qual-
`dynamic theories of both Arieti and Bibring. The patient was
`ities of the lost love object are transformedinto the crue] super-
`living his life for a dominant other—his father. He tried to per-
`ego. Hence, depressed persons feel that they are at the mercy
`
`102 of 173
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`

`SECTION 16.5 / MOOD DISORDERS: PSYCHODYNAMIC ETIOLOGY
`
`1119
`
`form beyond his abilities to extract an approving and loving
`response from his father that was never forthcoming. That
`longed-for response was rigidly construed as the only thing that
`mattered in life; even though he was succeeding at a highly
`competitive college, his success did not result in his feeling
`good about himself. Moreover, the patient's depression can also
`be linked to his awareness of the disparity between his idealized
`expectations of himself and the reality of his situation, as
`described by Bibring, Being a straight-A studentat Harvard was
`his own aspiration; the reality was that he was a B+ studentat
`a college that did not measure up to Harvard.
`The vignette also reflects two other key elements in the psy-
`chodynamic etiology of depression, First, in accord with the
`psychoanalytic notion of multiple causation, more than one psy-
`chodynamic theory may be pertinent in understanding an indi-
`vidual patient’s depression. Clearly, both the dominant other
`and the tension between ideals and realities were significant
`determinants in causing the patient’s depression, Second, the
`precipitating factors that produce depression do not have to be
`catastrophic events involving obvious external disasters, To a
`casual observerthe college student had no apparent reason to
`be depressed, since he was performing successfully at a highly
`regarded college. Nonetheless, the intrapsychic meaning of his
`academic performance was such that the patient felt hopeless
`and despairing as a result, In assessing the psychodynamic fac-
`tors in depression,clinicians must always attend to idiosyncratic
`personal meanings of events to fully understand the effects they
`have on the patient. Otherwise, clinicians run the risk of
`responding in the same unempathic manner that often charac-
`terizes the responses of family members. In the absence of
`objective evidence of any disastrous events in the depressed
`person’s life, loved ones often react by saying: “You have no
`reason to be depressed. Everything is going so well in your
`life.”*
`
`Selfobject failure The ego and the superego do notfigure in
`Heinz Kohut’s conceptualization of depression. Kohut’s theory,
`known as self psychology, rests on the assumption that the
`developing self has specific needs that must be met by parents
`to give the child a positive sense of self-esteem and self-cohe-
`sion and that similar responses are required from others
`throughout the course of the life cycle. He referred to those
`needs as mirroring, twinship, and idealization. The mirroring
`responses required by theself are equated with the gleam in the
`mother’s eye when the child exhibitionistically shows off for
`the mother, Admiration, validation, and affirmation are
`responses that are included under the category of mirroring,
`Twinship responsesrefer to the child's need to be like others.
`A small boy who is outside playing with his toy. lawn mower
`while his father is mowing the lawn is meeting important psy-
`chological needs in asserting his commonality with his father.
`Finally, the need for idealization is an important aspectof the
`development of the self. Children who grow up with parents
`they can respectand idealize develop healthy standards of con-
`f duct and morality.
`;
`», Kohutreferred to those three needs collectively as selfobject
`needs. In other words, the responses demanded from others are
`Trequired by the self, and the needs of the object as a separate
`| person are not taken into account. The other person serves as
`an object who meets the needs of the self. Selfobject needs
`3 essentially refer to certain functions that persons in the envi-
`ronment provide, rather than to those persons themselves.
`f Kohut felt that selfobject responses continue to be needed
`f
`throughout life and are as necessary for emotional health as
`a
`Oxygen is for physical health. Within that conceptual frame-
`
`work, depression involves the failure of selfobjects in the envi-
`ronment to provide the self of the depressed person with mir-
`roring, twinship, or idealizing responses necessary for the self
`to feel whole and sustained. The massiveloss of self-esteem
`seen in depression is regarded by Kohut and the self psychol-
`Ogists as a serious disruption of the self-selfobject connection
`or bond.
`
`Depression as affect and compromiseformation Among
`contemporary ego psychologists a widely held view is that
`depressionis not truly a psychiatric disorderorillness. Instead,
`depression is regarded as an affect reflecting conflict and com-
`promise formation. Charles Brenner, the principal architect of
`that view, suggested that concern about such childhood calam-
`ities as objectloss, loss of love, castration, and punishmentare
`associated with two kinds of unpleasure. One form of unplea-
`sure is anxiety, which involves an anticipated calamity or dan-
`ger. The other form of unpleasure, depressive affect, involves
`a calamity that has already happened. That theory of depressive
`affect differs sharply from the classical views of Freud and
`Abraham. Brenner pointed out that depression is not always
`related to object loss or to oral wishes. He also asserted that
`identification with a lost object is found in some depressed per-
`sons but notin all and that anger turned inwardis a result of
`depression, rather than a cause. Depressive affect, in Brenner's
`view, can be linked to any of the childhood calamities, rather
`than uniquely to object loss. People can experience depressive
`affect becausethey feel unloved, because they feel castrated, or
`because they feel punished in a variety of ways. Depressive
`affect is a normal and universal part of the human condition.
`A critical feature in Brenner's formulation is the idea of com-
`promise formation, in which a symptom is viewed as simulta-
`neously expressing an unconscious wish or drive and a defense
`against that wish or drive. A particular compromise formation
`may be more or less successful in eradicating depressive affect
`in the same manner as it may succeed to varying degrees in
`dealing with anxiety. A dog phobia, for example, is a symptom-
`atic compromise formation that succeedsin eliminating anxiety
`as long as dogs are avoided. Similarly, certain forms of com-
`promise formation may eradicate depressive affect while others
`do not.
`The central point of Brenner’s psychodynamictheory is that
`depressive affect is a universal feature in every pathological
`conflict, whether it is apparent on the surface or buried in the
`depths of the compromise formation. Depressiveaffect is a uni-
`versal factor in all cases of psychiatric illness, From that stand-
`point, Brenner believed that classifying certain forms of mental
`illness as depression simply because depressive affect is part of
`the conscious symptoms does not make sense. The conscious
`experience of depression provides information about the effi-
`cacy and the nature of a patient's defensive maneuvers and
`compromise formations, in Brenner’s view, but it does not
`reveal much about the underlying causes ofthe patient’s illness.
`
`Early deprivation Several investigators have noted that con-
`sistent, loving, nurturant parental involvement appears to have
`some value in preventing the development of depression. Con-
`versely, separation from parents early in life or the actual loss
`of a parent may predispose one to depression. Edith Zetzel
`observed that adverse experiences in the formative years of
`childhood, particularly those involving separation .and.
`loss,
`make it difficult for children to tolerate depressive affects with-
`out resorting to primitive defensive operations. If caretakers fail
`to assist children in identifying and tolerating painful feelings
`
`
`
`
`
`
`
`103 of 173
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`1120
`
`MOOD DISORDERS / CHAPTER 16
`
`that result from an adverse life experience, the child will grow
`up with inadequate coping mechanisms. That impaired adap-
`tation may contribute to the subsequent development of
`depression.
`;
`;
`Empirical research has provided some corroboration for the
`view that early deprivation is relevant to the cause of depres-
`sion. René Spitz demonstrated that infants separated from their
`mothers during the second six months of life have overt signs
`of depression.
`In some cases the infants in Spitz’s studies
`wasted away and died in responseto the separations. Margaret
`Mahler and her colleagues, who studied the interactions
`between normal and abnormal mother-infant pairs, found that
`children’s emotional dependence ontheir parents is instrumen-
`tal in the developmentoftheir capacity to grieve and mourn.
`That capacity, in turn, influences children’s feelings of self-
`esteem and helplessness. Although the development of depres-
`sion may involve genetic and constitutional factors, as well as
`environmental stressors, most theorists agree that the early rela-
`tionship between child and parent plays a significant role in
`causing depression.
`
`Premorbid personality factors A comprehensive psycho-
`dynamic understanding of depression must include, premorbid
`personality factors in the equation, All persons: may become
`depressed, given sufficient environmental stress, but certain
`personality types or traits appear to dispose one to depression.
`For example, the harsh, perfectionistic superego characteristic
`of persons with obsessive-compulsive personality disorder may
`lead them to feel that they are alwaysfalling short of their own
`excessive expectations of themselves. As noted earlier,
`that
`intrapsychic constellation maybe critical in the development of
`a major depressive episode, Similarly, Axis II personality dis-
`orders involving dependent yearnings for care—such as depen-
`dent, histrionic, and borderline personality disorders—mayalso
`be more vulnerable to depression. Those personality disorders
`that use projection and other externalizing defense mechanisms,
`such as antisocial and paranoid personality disorders, are less
`likely to decompensate into depression. No particular premor-
`bid personality type has been associated with the development
`of bipolar disorder,
`'
`Evidence is accumulating that an Axis II diagnosis of a per-
`sonality disordermay complicate the course and treatment of
`depression. Depressed patients with personality disorders gen-
`erally have poorer outcomes in the area of social functioning
`than those withoutpersonality disorders. Furthermore, residual
`depressive symptoms are more likely to present in recovering
`depressed patients who have an Axis II diagnosis. Psychoana-
`lytic clinicians have observed that personality factors frequently
`serve to maintain a depressed state once, it has occurred, In
`clinical practice the complicating factors of a comorbid person-
`ality disorder diagnosisare quite common.Onestudy found that
`42 percent of persons with major depressive disorder and 51
`percent of patients with dysthymic disorder have an accompa-
`nying Axis II diagnosis.
`
`CHARACTEROLOGICAL DEPRESSION Many patients
`encountered in clinical practice report feelings of depression
`even though they lack symptomsof a’ well-defined Axis I dis-
`order, such as major depressive episode, Manyof thosepatients
`have a primarydiagnosis of a personality disorder on Axis IT
`and experience characterological depression, a feeling of per-
`vasive loneliness or emptiness associated with the perception
`that others are not meeting one’s emotional needs, They can be
`distinguished frompatients with an Axis I diagnosis of major
`depressive episode by the absence of vegetative symptoms
`
`(such as psychomotor retardation, loss of libido, diminished
`appetite, lack ofenergy, and sleep disturbance) and by the pres-
`enceof certain qualitative features of their complaint of depres-
`sion, Loneliness, emptiness, and boredom are often chronic
`complaints in characterological depression but are much less
`common in Axis ] illnesses. In addition, a conscious sense of
`rage at not having their needs met may be present. The patients
`often describe childhood experiences in which they ‘felt
`deprived of appropriate emotional nurturance from their par-
`ents. As a result, they continue to seek parental substitutes in
`adult life.
`'
`Characterological depression is differentiated from Axis I
`personality disorders by the fact that it is an affective state
`occurring within the context of certain personality disorders,
`rather than a constellation oftraits forming an overarching per-
`sonality type:
`A 29-year-old woman came Semon complaining that she
`was ‘‘empty"’ inside and ‘‘needed
`to be filled up’’ by a positive expe-
`rience with a psychotherapist. She said that, while she was’ growing
`up, her mother never had time for her and that her mother loved her
`two sisters more than her, The patient had had a series of romantic
`relationships with men, but she neverfelt that she was getting the kind
`of attention and love that she needed from any of them. The menoften
`ended the relationship because they felt thal she was’ too demanding
`and that they could not
`possibly meetall her needs. Her last therapist
`had ‘given up"' on her
`because he, too,felt that he was unable to be
`of help to her. The patient also indicated that she had called, her pre-
`vious therapist almost every night because she would begin to feel
`lonely and need his reassurance that he still cared, She feared that she
`had turned off her therapist by being too demanding.She also described
`several angry outbursts directed at him when he would not talk with
`her for lengthy periods of time on the phone during the evening. She
`wondered if her outbursts made him hate-her.
`The patient had taken four different antidepressive medications with
`no improvement, She did not meet the diagnostic criteria for an Axis
`I dysthymic disorder or major Seceeaye
`isode. However, shedid
`have characteristics in keeping with
`two different Axis II diagnoses—
`dependentpersonality disorder and borderline personality disorder. ,
`
`OTHER CLINICALENTITIES In additionto the existence of
`characterological depression in the presence of other Axis. Il
`personality disorders, another clinical entity is described by
`psychoanalysts as depressive personality or depressive charac-
`ter. That disorder may be a form of chronic depression closely
`related to the Axis I diagnosis of dysthymic disorder. Persons
`suffering from the disorder exhibit the following symptoms:
`helplessness; chronic feelings of guilt; relationships ‘character-
`ized by dependency; persistent low self-esteem; an inclination
`to be self-punitive, self-denying, and hypercritical; and a con+
`viction thatthings are hopeless and will never change. Patients
`with that character structure do not allow themselves to have
`any form ofgratification in life because of disturbed relation-
`ships in childhood with parents or parental substitutes,
`‘
`A related form of characterological depression has been
`labeled depressive-masochistic personality disorder by’ Otto
`Kernberg. Patients’ with the disorder are characterized by an
`extremely demanding superegothat results inhumorless,overly
`conscientious, self-critical tendencies. The patients have exces-
`sive needs for approval, love, and acceptance from others, and
`they unconsciously cause others to feel guilty because of their
`inability to meet the patient's demands. The consequences of
`that pattern of interaction are further feelings of rejection
`because others do not wantto be part of a relationship in which
`“they never meet the expectations of the patient. People with
`depressive-masochistic ‘personalities are also characterologi-
`cally prone to tum anger inward to avoid any expression of
`aggression and anger toward others.
`|
`Clinicians must remember that depression spans the entire
`spectrum ofpathology andhealth. In addition to being a discrete
`
`104 of 173
`
`Alkermes, Ex. 1060
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`104 of 173
`
`Alkermes, Ex. 1060
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`

`

`SECTION 16.5 / MOOD DISORDERS: PSYCHODYNAMIC ETIOLOGY
`
`i121
`
`psychiatric disorder, depression refers to an emotional state that
`can be present in normal persons at certain times, as well as in
`persons with characterological or psychotic conditions. More-
`over, simply because the patient does not have sufficient symp-
`toms to be given an Axis I diagnosis of a mood disorder does
`not mean thatthe depression is benign. In one study, employees
`with minor forms of depression that did not meet Axis I criteria
`had 5] percent more disability days than did persons with a
`diagnosis of major depressive episode,
`
`Karl Abraham Most theories of mania view manic episodes
`as defensive against underlying depression. Karl Abraham, for
`example, believed that manic episodes may reflect an inability
`to tolerate childhood depression in reaction to a developmental
`tragedy, such as the loss of a parent. The ma